Doctor Data – About Our Credentialing Process
To make sure you have quality experiences with quality doctors, we make sure all of our doctors, PCPs
and specialists go through a credentialing process. This process ensures that our education and
training standards are met.
Credentialing helps you get the most from your health plan. How? By providing you with background
information so you feel confident that you’re getting great care. You want to know that your doctor is
board certified. We give that information to you. When it’s time for you to choose your doctor, you
may want this information to help you in making an educated choice. Knowing that your doctor has
completed all necessary requirements will give you peace of mind. We look at state licenses to make
sure that doctors meet our guidelines and those from the state. This information is monitored, and we
re-credential our doctors at least every three years.
Partnering with our doctors includes fair compensation for services. There are two ways they receive
payment for services:
1. Fee-for-service –
Each time you are seen for medical care, a bill is sent to us. The doctor is paid
according to a set fee schedule that has been established by us and agreed upon in advance by
2. Capitation –
The provider is paid a set amount every month regardless of howmuch care you receive.
Both methods are based on actual payment practices throughout the U.S.
It seems like there are new ideas in health care every day. From new drugs to tests to services, we
hear it all the time. We keep up with these new ideas so you can get the best medical care. We make
changes to our benefits and coverage based on these developments when needed. Once we know
there is something new that isn’t a covered benefit, we have our doctors take a very hard and
complete look at it.
Our process to accept a new technology:
• The doctors find all the facts they can to give a full report
• This information includes evaluations and input from other health care professionals who are
• After all the facts are in, the new advancement has a very tough test to go through to see if it is
good for our members
• At the end, we review the advancement with our Benefit Advisory Committee to see if it will be
a new benefit
• Medical professionals review and finalize all benefit policy rulings
You need to tell us about all emergency admissions within 48 hours. The phone number is on the back
of your ID card. If you are admitted to a hospital that isn’t affiliated with your health plan, we will call
the doctor treating you to check your status and your care plan. When it is safe, you may be
transferred to an affiliated hospital. If you say no to the move, your care at the hospital that isn’t
affiliated will be covered at a reduced benefit level.